topic instrument question responses...ethnicity the name of my tribe is... background about this...

Topic Instrument Question Responses

Introduction Welcome!

Thank you for joining iCureCeliac. The

information that you contribute will

make it possible for there to be new

treatments, and one day, a

cure.This survey will take

approximately 45-60 minutes to

complete, depending on how much detail

you provide.If you get tired, you

can take a break and when you return,

continue from where you left off.

However, it is very important

that you complete the entire survey

 so that everyone in the

community has answered the same

questions. Thank you for your

willingness to take part in this important

work. Select "Continue" to get

started...

Demographics

Let's get

started...

We would like to ask you a few

questions about yourself. This will help

researchers to better understand how

your gluten-related disorder affects you,

as well as different people of all ages,

genders, and ethnicities. We will begin

with some basic questions.

Demographics Gender My gender (self-identified) is...

Female,Male,Other (specify

on next question)

Demographics Gender

I describe my gender as "Other" because

I am...

Intersex (ambiguous at

birth),Intersex (XXY, XXYY

or other chromosomal

variation from XX-female or

XY-male),Male-to-female

transsexual,Female-to-male

transsexual,Other

Demographics Gender My gender is...

Demographics Birthplace I was born in...

United

States,Canada,Caribbean,Me

xico,United Kingdom,Other

European

Countries,Africa,Asia,Central

America,Middle East,South

America,South Pacific,Other

Demographics Birthplace

The specific European country in which I

was born is...

France,Germany,Ireland,Ital

y,Netherlands,Spain,Switzerl

and,Other


The specific Caribbean country in which I

was born is...

Aruba,Bahama

Islands,Dominican

Republic,Jamaica,Other


The specific African country in which I

was born is...

Egypt,Morocco,Senegal,Sout

h Africa,Other


The specific South American country in

which I was born is...

Argentina,Brazil,Columbia,P

eru,Venezuela,Other


The specific Central American country in


Costa Rica,El

Salvador,Guatemala,Panam

a,Other


The specific Asian country in which I was

born is...

China / Mainland,China /

Taiwan,Hong

Kong,India,Japan,Korea,Phill

ipines,Other


The specific Middle Eastern country in


Yemen,Oman,Saudi

Arabia,Jordan,Egypt,United

Arab

Emirates,Israel,Kuwait,Qata

r,Lebanon,Bahrain,Other


The specific South Pacific country in


Australia,New

Zealand,Polynesia,Other


The specific country in which I was born

is...

Demographics Birthplace The state in which I was born is...

Alabama,Alaska,Arizona,Ark

ansas,California,Colorado,Co

nnecticut,Delaware,Florida,G

eorgia,Hawaii,Idaho,Illinois,I

ndiana,Iowa,Kansas,Kentuck

y,Louisiana,Maine,Maryland,

Massachusetts,Michigan,Min

nesota,Mississippi,Missouri,

Montana,Nebraska,Nevada,

New Hampshire,New

Jersey,New Mexico,New

York,North Carolina,North

Dakota,Ohio,Oklahoma,Oreg

on,Pennsylvania,Rhode

Island,South Carolina,South

Dakota,Tennessee,Texas,Ut

ah,Vermont,Virginia,Washin

gton,West

Virginia,Wisconsin,Wyoming,

Puerto Rico,District of

Columbia,Northern Mariana

Islands,United States Virgin

Islands,American

Samoa,Guam


The city, town or village in which I was

born is...

Demographics

Race &

Ethnicity My race or origin is...

American Indian or Alaskan

Native (i.e. Navajo, Mayan,

Tlingit, etc.),Asian (i.e.

Asian Indian, Chinese,

Filipino, Japanese, Korean,

Vietnamese, Hmong,

Laotian, Thai, Pakistani,

Cambodian, etc.),Black or

African American (i.e.

African American, Haitian,

Nigerian, etc.),Hispanic,

Latino, or Spanish origin

(i.e. Mexican, Mexican

American, Puerto Rican,

Cuban, Argentinian,

Colombian, Dominican,

Nicaraguan, Salvadorian,

Spaniard, etc.),Native

Hawaiian or Other Pacific

Islander (i.e. Native

Hawaiian, Guamanian or

Chamorro, Samoan, Fijian,

Tongan, etc.),White (i.e.,

European, Middle Eastern,

Northern Africa, etc.),Some

other race or origin

Demographics

Race &

Ethnicity More specifically my Asian heritage is...

Asian

Indian,Chinese,Filipino,Japa

nese,Korean,Vietnamese,H

mong,Laotian,Indonesian,Th

ai,Cambodian,Malaysian,Pak

istani,Sri

Lankan,Bangladeshi,Other

Demographics

Race &

Ethnicity

More specifically my Pacific Islander

heritage is...

Native

Hawaiian,Guamanian,Chamo

rro,Samoan,Fijian,Tongan,O

ther

Demographics

Race &

Ethnicity

More specifically my Hispanic or Latino

heritage is...

Mexican,Puerto

Rican,Cuban,Central

American,South

American,Other Spanish,

Hispanic or Latino

Demographics

Race &

Ethnicity

More specifically my "Other" background

is...

Demographics

Race &

Ethnicity The name of my tribe is...

Background

About this

section:

Your background is important to

understanding your condition and any

support you might need. Thank you for

replying to these questions.

Remember if you get tired, you can

take a break and when you return,

continue from where you left off.

Background

Grandparent

Ancestry

My maternal grandmother describes or

described her ancestors as...

Afghan,Albanian,Algerian,A

merican,Andorran,Angola,An

tiguans, Argentinean,

Armenian, Australian,

Austrian, Azerbaijani,

Bahamian, Bahraini,

Bangladeshi, Barbadian,

Barbudans, Batswana,

Belarusian, Belgian,

Belizean, Beninese,

Bhutanese, Bolivian,

Bosnian, Brazilian, British,

Bruneian, Bulgarian,

Burkinabe, Burmese,

Burundian, Cambodian,

Cameroonian, Canadian,

Cape Verdean, Central

African, Chadian, Chilean,

Chinese, Colombian,

Comoran, Congolese, Costa

Rican, Croatian, Cuban,

Cypriot, Czech, Danish,

Djibouti, Dominican, Dutch,

East Timorese, Ecuadorean,

Egyptian, Emirian,

Equatorial Guinean,

Eritrean, Estonian,

Ethiopian, Fijian, Filipino,

Finnish, French, Gabonese,

Gambian, Georgian,

German, Ghanaian, Greek,

Grenadian, Guatemalan,

Guinea-Bissauan, Guinean,

Guyanese, Haitian,

Herzegovinian, Honduran,

Hungarian, I-Kiribati,

Icelander, Indian,

Indonesian, Iranian, Iraqi,

Background

Grandparent

Ancestry

My maternal grandfather describes or

described his ancestors as...


merican,Andorran,Angolan,

Antiguans, Argentinean,



Bahamian, Bahraini,




Belizean, Beninese,




Burkinabe, Burmese,





Chinese, Colombian,






Egyptian, Emirian,

Equatorial Guinean,

Eritrean, Estonian,



Gambian, Georgian,




Guyanese, Haitian,



Icelander, Indian,


Background

Grandparent

Ancestry

My paternal grandmother describes or

described her ancestors as...

Afghan, Albanian, Algerian,

American, Andorran,

Angolan, Antiguans,

Argentinean, Armenian,

Australian, Austrian,

Azerbaijani, Bahamian,

Bahraini, Bangladeshi,

Barbadian, Barbudans,

Batswana, Belarusian,

Belgian, Belizean, Beninese,




Burkinabe, Burmese,





Chinese, Colombian,






Egyptian, Emirian,

Equatorial Guinean,

Eritrean, Estonian,



Gambian, Georgian,




Guyanese, Haitian,



Icelander, Indian,


Background

Grandparent

Ancestry

My paternal grandfather describes or

described his ancestors as...


merican,Andorran,Angolan,

Antiguans, Argentinean,



Bahamian, Bahraini,




Belizean, Beninese,




Burkinabe, Burmese,





Chinese, Colombian,






Egyptian, Emirian,

Equatorial Guinean,

Eritrean, Estonian,



Gambian, Georgian,




Guyanese, Haitian,



Icelander, Indian,


Background Insurance About these questions...

Background Insurance

The type of health insurance that I use

is...

Medicare,Medicaid,Health

Maintenance Organization

(HMO),Preferred Provider

Organization (PPO),High-

Deductible Health Plan

(HDHP),Military Health

Benefits (DoD),Veterans

Health Administration

(VA),State Children's Health

Insurance Program

(SCHIP),Indian Health

Service (IHS),State Risk

Pool,Other,No health

insurance


The other type of health insurance that I

use is...


The insurer, if any, that I receive my

health insurance from is...

Aetna Group,Blue Cross

Blue Shield,California

Physicians' Service,Cambia

Health Solutions

Inc.,Carefirst Inc.

Group,Centene Corp.

Group,Cigna Health

Group,Coventry Corp.

Group,HCSC Group,Health

Net of California,

Inc.,Highmark Group,HIP

Insurance Group,Humana

Group,Independence Blue

Cross Group,Kaiser

Foundation Group,Lifetime

Healthcare

Group,Metropolitan

Group,Molina Healthcare

Inc. Group,UHC of

California,United

Healthgroup,Wellcare

Group,Wellpoint Inc.

Group,Other


My company is Blue Cross Blue Shield

of...

Alabama,Alaska,Arizona,Ark

ansas,California,Colorado,Co

nnecticut,Delaware,Florida,G

eorgia,Hawaii,Idaho,Illinois,I

ndiana,Iowa,Kansas,Kentuck

y,Louisiana,Maine,Maryland,

Massachusetts,Michigan,Min

nesota,Mississippi,Missouri,

Montana,Nebraska,Nevada,

New Hampshire,New

Jersey,New Mexico,New

York,North Carolina,North

Dakota,Ohio,Oklahoma,Oreg

on,Pennsylvania,Rhode

Island,South Carolina,South

Dakota,Tennessee,Texas,Ut

ah,Vermont,Virginia,Washin

gton,West

Virginia,Wisconsin,Wyoming,

District of Columbia


The insurer, if any, I receive insurance

from is called...

Background Insurance My health insurance is provided by...

Work or school pays for

it,Spouse or guardian's work

pays for it,Purchase through

work or school,Purchased

through a health

exchange,Privately

purchased from a insurance

company,Other


The other place I get my insurance from

is...


I have received health insurance from

my current company for the last...

Month,3 months,6 months,9

months,1 year,2 years,3 to

5 years,More than 5 years

Background Insurance In general, my medical expenses are...

Not covered,Covered a

little,Mostly

covered,Completely covered


My health has impacted my ability to get

insurance...

Not at all,Health

insurance,Life

insurance,Long-term care

insurance,Disability

insurance,Don't know

Background Environment

The environment in which I grew up in

was: Urban,Suburban,Rural

Background Environment My childhood pets included:

Cat,Dog,Rabbit,Other,No

pets

Background Environment

Please provide a short explanation of the

other pet:

General Health

Weight &

Height

Please select system of measurement for

weight and height...

U.S. Customary System or

the inch-pound system in

lbs or ft-in (example: 150

lbs and 5 ft, 6

in),International System of

Units or the metric system

in kg or m-cm (example: 60

kg and 1m70cm)

General Health

Weight &

Height My current weight is approximately...

Under 100 lbs ,100 lbs ,101

lbs ,102 lbs ,103 lbs,104 lbs

,105 lbs ,106 lbs ,107 lbs

,108 lbs ,109 lbs ,110 lbs

,111 lbs ,112 lbs ,113 lbs

,114 lbs ,115 lbs ,116 lbs

,117 lbs ,118 lbs,119

lbs,120 lbs,121 lbs,122

lbs,123 lbs,124 lbs,125

lbs,126 lbs,127 lbs,128

lbs,129 lbs,130 lbs,131

lbs,132 lbs ,133 lbs ,134 lbs

,135 lbs ,136 lbs,137 lbs

,138 lbs ,139 lbs ,140

lbs,141 lbs,142 lbs,143

lbs,144 lbs,145 lbs,146

lbs,147 lbs,148 lbs,149

lbs,150 lbs,151 lbs,152

lbs,153 lbs,154 lbs,155

lbs,156 lbs,157 lbs,158

lbs,159 lbs,160 lbs,161

lbs,162 lbs,163 lbs,164

lbs,165 lbs,166 lbs,167

lbs,168 lbs,169 lbs,170

lbs,171 lbs,172 lbs,173

lbs,174 lbs,175 lbs,176

lbs,177 lbs,178 lbs,179

lbs,180 lbs,181 lbs ,182

lbs,183 lbs,184 lbs,185

lbs,186 lbs,187 lbs,188

lbs,189 lbs,190 lbs,191

lbs,192 lbs,193 lbs,194

lbs,195 lbs,196 lbs,197

lbs,198 lbs,199 lbs,200

lbs,201 lbs,202 lbs,203

lbs,204 lbs,205 lbs,206

lbs,207 lbs,208 lbs,209

lbs,210 lbs,211 lbs,212

General Health

Weight &


Under 45 kg ,45 kg ,46

kg,47 kg,48 kg,49 kg,50

kg,51 kg,52 kg,53 kg,54

kg,55 kg,56 kg,57 kg,58

kg,59 kg,60 kg,61 kg,62

kg,63 kg,64 kg,65 kg,66

kg,67 kg,68 kg,69 kg,70

kg,71 kg,72 kg,73 kg,74

kg,75 kg,76 kg,77 kg,78

kg,79 kg,80 kg,81 kg,82

kg,83 kg,84 kg,85 kg,86

kg,87 kg,88 kg,89 kg,90

kg,91 kg,92 kg,93 kg,94

kg,95 kg,96 kg,97 kg,98

kg,99 kg,100 kg,101 kg,102

kg,103 kg,104 kg,105

kg,106 kg,107 kg,108

kg,109 kg,110 kg,111

kg,112 kg,113 kg,114

kg,115 kg,Over 115 kg

General Health

Weight &


251 lbs ,252 lbs ,253

lbs,254 lbs,255 lbs,256

lbs,257 lbs,258 lbs,259

lbs,260 lbs,261 lbs,262 lbs

,263 lbs,264 lbs,265 lbs,266

lbs,267 lbs,268 lbs,269

lbs,270 lbs,271 lbs,272

lbs,273 lbs,274 lbs,275

lbs,276 lbs,277 lbs,278

lbs,279 lbs,280 lbs,281

lbs,282 lbs,283 lbs,284

lbs,285 lbs,286 lbs,287

lbs,288 lbs,289 lbs,290

lbs,291 lbs,292 lbs,293

lbs,294 lbs,295 lbs,296

lbs,297 lbs,298 lbs,299

lbs,300 lbs,301 lbs,302

lbs,303 lbs,304 lbs,305

lbs,306 lbs,307 lbs,308

lbs,309 lbs,310 lbs,311

lbs,312 lbs,313 lbs,314

lbs,315 lbs,316 lbs,317

lbs,318 lbs,319 lbs,320

lbs,321 lbs,322 lbs,323

lbs,324 lbs,325 lbs,326

lbs,327 lbs,328 lbs,329

lbs,330 lbs,331 lbs,332

lbs,333 lbs,334 lbs,335

lbs,336 lbs,337 lbs,338

lbs,339 lbs,340 lbs,341

lbs,342 lbs,343 lbs,344

lbs,345 lbs,346 lbs,347

lbs,348 lbs,349 lbs,350

lbs,351 lbs,352 lbs,353

lbs,354 lbs,355 lbs,356

lbs,357 lbs,358 lbs,359

lbs,360 lbs,361 lbs,362

lbs,363 lbs,364 lbs,365

General Health

Weight &


116 kg ,117 kg ,118 kg

,119 kg ,120 kg,121 kg,122

kg,123 kg,124 kg,125

kg,126 kg,127 kg,128

kg,129 kg,130 kg,131

kg,132 kg,133 kg ,134

kg,135 kg,136 kg,137

kg,138 kg,139 kg,140

kg,141 kg,142 kg,143

kg,144 kg,145 kg,146

kg,147 kg,148 kg,149

kg,150 kg,151 kg,152

kg,153 kg,154 kg,155

kg,156 kg,157 kg,158

kg,159 kg,160 kg,161

kg,162 kg,163 kg,164

kg,165 kg,166 kg,167

kg,168 kg,169 kg,170

kg,171 kg,172 kg,173

kg,174 kg,175 kg,176

kg,177 kg,178 kg,179

kg,180 kg,181 kg,182

kg,183 kg,184 kg,185

kg,186 kg,187 kg,188

kg,189 kg,190 kg,191

kg,192 kg,193 kg,194

kg,195 kg,196 kg,197

kg,198 kg,199 kg,200

kg,201 kg,202 kg,203

kg,204 kg,205 kg,206

kg,207 kg,208 kg,209

kg,210 kg,211 kg,212

kg,213 kg,214 kg,215

kg,216 kg,217 kg,218

kg,219 kg,220 kg,221

kg,222 kg,223 kg,224

kg,225 kg,226 kg,227

kg,228 kg,229 kg,230

General Health

Weight &


99 lbs ,98 lbs ,97 lbs ,96

lbs,95 lbs ,94 lbs ,93 lbs ,92

lbs ,91 lbs,90 lbs ,89 lbs ,88

lbs ,87 lbs ,86 lbs ,85 lbs

,84 lbs ,83 lbs ,82 lbs ,81


,77 lbs ,76 lbs ,75 lbs ,74


,70 lbs ,69 lbs ,68 lbs ,67

lbs ,66 lbs ,65 lbs ,64 lbs,63


,59 lbs ,58 lbs ,57 lbs ,56


,52 lbs ,51 lbs ,50 lbs ,49


,45 lbs ,44 lbs ,43 lbs ,42


,38 lbs ,37 lbs ,36 lbs ,35

lbs,34 lbs ,33 lbs,32 lbs ,31


,27 lbs ,26 lbs ,25 lbs ,24

lbs ,23 lbs,22 lbs,21 lbs ,20


,16 lbs ,15 lbs ,14 lbs ,13

lbs ,12 lbs ,11 lbs ,10 lbs ,9

lbs ,8 lbs,7 lbs ,6 lbs ,5 lbs

,4 lbs ,3 lbs ,2 lbs ,1 lb ,11

oz ,10 oz ,9 oz ,8 oz ,7 oz

,6 oz ,5 oz ,4 oz ,3 oz ,2 oz

,1 oz

General Health

Weight &


44 kg ,43 kg ,42 kg,41 kg

,40 kg ,39 kg ,38 kg ,37 kg

,36 kg ,35 kg ,34 kg ,33 kg

,32 kg ,31 kg ,30 kg ,29 kg

,28 kg ,27 kg ,26 kg ,25 kg

,24 kg ,23 kg,22 kg ,21 kg

,20 kg ,19 kg ,18 kg ,17 kg

,16 kg ,15 kg,14 kg ,13

kg,12 kg ,11 kg ,10 kg ,9

kg ,8 kg ,7 kg ,6 kg ,5 kg,4

kg ,3 kg ,2 kg,1 kg

General Health

Weight &

Height My current height is approximately...

Under 5' 0",5' 0",5' 1",5'

2",5' 3",5' 4",5' 5",5' 6",5'

7",5' 8",5' 9",5' 10",5'

11",6' 0",6' 1",6' 2",6' 3",6'

4",6' 5",6' 6",Over 6' 6"

General Health

Weight &


Under

1m50cm,1m50cm,1m51cm,

















2m,Over 2m

General Health

Weight &


6' 7",6' 8",6' 9",6' 10",6'

11",7' 0",7' 1",7' 2",7' 3",7'

4",7' 5",7' 6",7' 7",7' 8",7'

9",7' 10",7' 11",8' 0",8'

1",8' 2",8' 3",8' 4",8' 5",8'

6",8' 7",8' 8",8' 9",8' 10",8'

11",9' 0"

General Health

Weight &



































3m

General Health

Weight &


4' 11",4' 10",4' 9",4' 8",4'

7",4' 6",4' 5",4' 4",4' 3",4'

2",4' 1",4' 0",3' 11",3'

10",3' 9",3' 8",3' 7",3' 6",3'

5",3' 4",3' 3",3' 2",3' 1",3'

0",2' 11",2' 10",2' 9",2'

8",2' 7",2' 6",2' 5",2' 4",2'

3",2' 2",2' 1",2' 0",1' 11",1'

10",1' 9",1' 8",1' 7",1' 6",1'

5",1' 4",1' 3",1' 2",1' 1",1'

0",0' 11",0' 10",0' 9",0'

8",0' 7",0' 6",0' 5",0' 4",0'

3",0' 2",0' 1"

General Health

Weight &















1m10cm,1m9cm,1m8cm,1

m7cm,1m6cm,1m5cm,1m4c

m,1m3cm,1m2cm,1m1cm,1

mcm,99cm,98cm,97cm,96c

m,95cm,94cm,93cm,92cm,9

1cm,90cm,89cm,88cm,87c

m,86cm,85cm,84cm,83cm,8


m,77cm,76cm,75cm,74cm,7


m,68cm,67cm,66cm,65cm,6


m,59cm,58cm,57cm,56cm,5


m,50cm,49cm,48cm,47cm,4


m,41cm,40cm,39cm,38cm,3


m,32cm,31cm,30cm,29cm,2


m,23cm,22cm,21cm,20cm,1


m,14cm,13cm,12cm,11cm,1

0cm,9cm,8cm,7cm,6cm,5c

m,4cm,3cm,2cm,1cm

Gluten-Related

Disorder History

About this

section:

Our research and medical communities

have a number of questions about your

gluten-related disorder. This section

covers your physical and emotional

experiences.

Gluten-Related

Disorder History

Diagnosis

and Care

My diagnosed gluten-related disorder is

(check as many as apply):

Celiac Disease,Refractory

Celiac Disease Type

I,Refractory Celiac Disease

Type II,Refractory Celiac

Disease (Type

Uncertain),Non-Celiac

Gluten Sensitivity,Gluten

Ataxia,Dermatitis

Herpetiformis (DH),Wheat

Allergy/Intolerance,Other

gluten-related disorder,Self-

diagnosed with a gluten-

related disorder,Not

diagnosed with a gluten-

related disorder

Gluten-Related

Disorder History

Diagnosis

and Care

Please describe the other gluten-related

disorder:

Gluten-Related

Disorder History

Diagnosis

and Care

I first experienced symptoms of my

gluten-related disorder on this date:

Gluten-Related

Disorder History

Diagnosis

and Care

The length of time from the first

symptoms of my gluten-related disorder

to my first healthcare appointment for

them was:

< 1 month,1-2 months,3-6

months,7-12 months,1-2

years,2-5 years,5-7 years,7-

10 years,10-15 years,15-20

years,20-25 years,> 25

years,Never had a

healthcare appointment for

symptoms,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care

My first healthcare appointment for

symptoms of my gluten-related disorder

was on this date:

Gluten-Related

Disorder History

Diagnosis

and Care

The length of time to diagnosis from the

first symptoms of my gluten-related

disorder was:


mos,7-12 mos,1-2 years,2-

5 years,5-7 years,7-10

years,10-15 years,15-20


years,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care

The specific date of diagnosis of my

gluten-related disorder was:

Gluten-Related

Disorder History

Diagnosis

and Care

I was this age when first diagnosed with

my gluten-related disorder:

Don't know,Less than 4

years old,4 years old,5






























years old,64 years

old,Greater than 65 years

Gluten-Related

Disorder History

Diagnosis

and Care

The age (in months) that I was first

diagnosed:

Gluten-Related

Disorder History

Diagnosis

and Care

The following best describes my initial

diagnosis:

Clinical diagnosis by

physician based on

symptoms,Clinical diagnosis

by physician based on

family history,Diagnosis by

healthcare professional

other than a physician,Was

not given a diagnosis but

was told by healthcare

provider to try a gluten-free

diet,Self-

diagnosis,Other,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care

Please describe the other initial

diagnosis:

Gluten-Related

Disorder History

Diagnosis

and Care

Please select the physician type who

diagnosed you (check as many as

apply):

Endocrinologist,Family

Medicine

Practitioner,Gastroenterologi

st,Internist,Obstetrician/Gyn

ecologist,Pediatrician,Pediatr

ic Endocrinologist,Pediatric

Gastroenterologist,Pediatric

Rheumatologist,Rheumatolo

gist,Other physician

type,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care Please describe the other physician type:

Gluten-Related

Disorder History

Diagnosis

and Care

Please select the other healthcare

professional who diagnosed you (check

all that apply):

Chiropractor,Dietitian,Dentis

t,Naturopath,Nutritionist,Oth

er non-physician healthcare

professional,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care

Please describe the other non-physician

healthcare professional:

Gluten-Related

Disorder History

Diagnosis

and Care

The tests used to diagnose me were


Celiac Disease panel blood

test,Biopsy of the intestine

or small bowel during upper

endoscopy,HLA (genetic)

testing,Skin biopsy,Gluten

challenge,ALCAT food

sensitivity test,Stool

test,Saliva test,Allergy skin

test,Other test(s),No tests

but respond well to a gluten-

free diet,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care Please describe the other test(s):

Gluten-Related

Disorder History

Diagnosis

and Care

The specific celiac disease blood tests

used to diagnosis me were (check as

many as apply):

Tissue Transglutaminase

(tTG),IgA Endomysial

antibody (EMA),Deamidated

Gliadin Peptide (DGP),Anti

Gliadin Antibodies,Total

serum IgA,Other celiac

disease blood test,Don't

know

Gluten-Related

Disorder History

Diagnosis

and Care

Please describe the other celiac disease

blood tests:

Gluten-Related

Disorder History

Diagnosis

and Care

At the time of diagnosis, I was told by

my healthcare provider that I would

grow out of my gluten-related disorder: Yes,No,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care

I grew out of my gluten-related

disorder: Yes,No,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care


my healthcare provider to follow a strict,

gluten-free diet for the rest of my life: Yes,No,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care


my healthcare provider to seek

nutritional counseling: Yes,No,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care

At the time of diagnosis, I sought

nutritional counseling: Yes,No,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care

After diagnosis, I sought nutritional

counseling within:


months,7-12 months,1-2

years,2-5 years,5-7 years,7-

10 years,10-15 years,15-20


years,Never sought

nutritional counseling,Don't

know

Gluten-Related

Disorder History

Diagnosis

and Care

I have never sought nutritional

counseling because (check as many as

apply):

Not told by healthcare

provider to seek nutritional

counseling for gluten-related

disorder,Diagnosing

healthcare provider

provided enough

information,Enough

information available

through the internet, books

or magazines,Enough

information provided by a

foundation or support

group,Already familiar with

the nutritional requirements

for gluten-related

disorder,No local

dietitian/nutritionist

knowledgeable about gluten-

related disorder,Do not trust

dietitians/nutritionists,For

financial reasons -

uninsured,For financial

reasons - insured but co-

pay too high,For financial

reasons - insured but not a

covered benefit,Do not think

nutritional counseling is

helpful for gluten-related

disorder,Other reason,Don't

know

Gluten-Related

Disorder History

Diagnosis

and Care Please describe the other reason:

Gluten-Related

Disorder History

Diagnosis

and Care

I am still symptomatic even though I

follow a strict gluten-free diet: Yes,No,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care

My dentist is familiar with my gluten-

related disorder: Yes,No,Don't know

Gluten-Related

Disorder History

Diagnosis

and Care

To evaluate my current health, I would

be willing to undergo: Yes,No,Unsure

Gluten-Related

Disorder History

Living with a

Gluten-

Related About this section:

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

My gluten-related disorder is currently

managed by my (check as many as

apply):

Chiropractor,Dietitian,Endoc

rinologist,Family Medicine

Practitioner,Gastroenterologi

st,Internist,Naturopath,Nutri

tionist,Obstetrician/Gynecol

ogist,Pediatrician,Pediatric

Endocrinologist,Pediatric



gist,Other healthcare

provider,Self-managed,Not

managed,Gluten-related

disorder does not require

management

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Please describe the other healthcare

provider:

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

I see my healthcare provider for my

gluten-related disorder this frequently:

Less than

monthly,Monthly,2-5

months,6-11

months,Annually,13-24

months,25-36 months,37-

48 months,49-60

months,More than 5

years,No healthcare

provider ever seen

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

I haven't visited a healthcare provider

within the past 5 years to specifically

discuss or manage my gluten-related

disorder because (check as many as

apply):

Doing a good job of

managing gluten-related

disorder and don't need to

see a heathcare provider for

it,Have not had a reason to

see a healthcare provider

about gluten-related

disorder,Do not trust

healthcare providers,Have

not found healthcare

provider(s) to be

knowledgeable about gluten-

related disorder,Have not

found previous visits to be

helpful for gluten-related

disorder,For financial

reasons -uninsured,For

financial reasons - insured,

but co-pay is too high,For

financial reasons - not a

covered benefit,Visited a

healthcare provider within

the past 5 years,Don't

know,Other reason

Gluten-Related

Disorder History

Living with a

Gluten-

Related Please describe the other reason:

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

My health has improved since my

diagnosis:

Not at all,A little

bit,Somewhat,Quite a

bit,Very much

Gluten-Related

Disorder History

Living with a

Gluten-

Related

My health in relation to my gluten-

related disorder is:

Terrible,Fair,Poor,Good,Exce

llent

Gluten-Related

Disorder History

Living with a

Gluten-

Related My overall health is:

Terrible,Fair,Poor,Good,Exce

llent

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

Keeping my gluten-related disorder in

mind and in relation to my health, I

would say that I am comfortable:

Strongly

Disagree,Somewhat

Disagree,Neither Agree or

Disagree,Somewhat

Agree,Strongly Agree

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder I am just as healthy as anybody I know.

Strongly

Disagree,Somewhat

Disagree,Neither Agree or

Disagree,Somewhat

Agree,Strongly Agree

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

My primary source of information for

living with my gluten-related disorder is:

Chiropractor,Dietitian,Endoc

rinologist,Family Medicine

Practitioner,Internist,Gastro

enterologist,Naturopath,Nutr

itionist,Obstetrician/Gynecol

ogist,Pediatrician,Pediatric

Endocrinologist,Pediatric



gist,Other healthcare

provider,Book,Foundation or

support group,Social

media,Magazine,Website,Ot

her primary information

source,Do not use a primary

information source,Don't

know

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Please describe the other primary

information source:

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Please describe the other healthcare

provider:

Gluten-Related

Disorder History

Living with a

Gluten-

Related Please describe the book(s):

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Please describe the foundation or

support group:

Gluten-Related

Disorder History

Living with a

Gluten-

Related Please describe the magazine(s):

Gluten-Related

Disorder History

Living with a

Gluten-

Related Please describe which social media:

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

My primary website for information on

my gluten-related disorder is...

Celiac Disease Foundation

(celiac.org),about.com,celiac

.com,Celiac Support

Association

(csaceliacs.org),CeliacNow,C

olumbia University Celiac

Disease Center,Gluten

Intolerance Group

(gluten.org),MassGeneral

Center for Celiac

Research,Mayo

Clinic,National Institute of

Health,National Foundation

for Celiac Awareness

(celiacentral.org),University

of Chicago Celiac Disease

Center,sharecare.com,WebM

D,Other website,Do not use

a website,Don't know

Gluten-Related

Disorder History

Living with a

Gluten-

Related Please describe the other website:

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

I get blood work for my gluten-related

disorder this frequently:

Daily,2-3 times each

week,Weekly,Every two

weeks,Monthly,Every two

months,Every three

months,Every Six

Months,Annually

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

Regarding future monitoring of my

gluten-related disorder, I would utilize


Administered by a

healthcare provider,Self-

administered,Not interested

in monitoring

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

An acceptable frequency for healthcare

provider monitoring of my gluten-related

disorder is:



weeks,Monthly,Every two

months,Every three

months,Every six

months,Annually,Less than

once a year

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

An acceptable frequency for self-

monitoring of my gluten-related disorder

is:

Daily,2-3

times/week,Weekly,Twice

monthly,Monthly,Every 2

months,Every 3

months,Every 6

months,Annually,Less than

once a year

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

To monitor my gluten-related disorder,

the maximum monthly out-of-pocket

cost I would be willing to pay is:

<$10,$10-$25,$26-$50,$51-

$75,$76-$100,$101-

$150,>$150,Not willing to

pay for treatment

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

Assuming there is no complete cure

(ability to eat gluten without symptoms

and intestinal damage) for my gluten-

related disorder, the ideal treatment

would be:

Ability to eat gluten

whenever, without

symptoms,A backup plan

when exposed to gluten

accidentally to mitigate

symptoms,Symptom

improvement for ongoing

symptoms that haven't

improved on the gluten-free

diet,Improvement of

intestinal

inflammation/complications

that has not improved on a

gluten-free diet,Not

interested in a gluten-

related disorder treatment

other than a strict gluten-

free diet,Not interested in a

gluten-related disorder

treatment,Other

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Please describe the other ideal

treatment:

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

Regarding a future medication or

treatment for my gluten-related

disorder, I would utilize (check as many

as apply):

Injectable drug

administered in healthcare

provider office,Self-

administered injectable

drug,Over the Counter

(OTC) inhaler,Prescription

inhaler,Over the Counter

(OTC) oral

medication,Prescription oral

medication,Over the

Counter (OTC)

suppository,Prescription

suppository,Over the

Counter (OTC) transdermal

(skin) patch,Prescription

transdermal (skin)

patch,Not interested in a

medication or treatment for

gluten-related disorder

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

An acceptable frequency for treatment of

my gluten-related disorder by my

healthcare provider administered

injectable is (check as many as apply):



weeks,Monthly,Every Two

Months,Every Three

Months,Every Six

Months,Annually,Less than

once a year

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

An acceptable frequency for self-

treatment of my gluten-related disorder

is (check as many as apply):

With each meal,4

times/day,3 times/day,2

times/day,Daily,Weekly,2- 3

times/week,Monthly,Less

than once a month,Never

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

To treat my gluten-related disorder I

would be willing to tolerate (check as

many as apply):

No side effects,Mild side

effects,Moderate side

effects,Severe side effects

Gluten-Related

Disorder History

Living with a

Gluten-

Related

Disorder

To treat my gluten-related disorder, the

maximum monthly out-of-pocket cost I

would be willing to pay is:

<$10,$10-$25,$26-$50,$51-

$75,$76-$100,$101-

$150,>$150,Not willing to

pay for treatment

Gluten-Related

Disorder History

Dietary

Adherence About this section:

Gluten-Related

Disorder History

Dietary

Adherence I keep a strict gluten-free diet.

Never,Rarely,Sometimes,Oft

en,Always

Gluten-Related

Disorder History

Dietary

Adherence

I am able to follow a gluten-free diet

when dining outside my home.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence

I am annoyed or frustrated by trying to

find gluten-free food.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence

I am annoyed or frustrated trying to find

gluten-free medications.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence

When dining out, I tell my server about

my gluten-related disorder and dietary

requirements.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence

When dining at someone else's home I

tell them about my gluten-related

disorder and dietary requirements.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence

I feel uncomfortable about other people

having to cater to my diet.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence

I find it difficult to explain my dietary

needs to others.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence

I am annoyed or frustrated about the

cost of gluten-free food.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence

I feel guilty about other people buying

gluten-free foods for me.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence I check product labels for gluten.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence

I check these product labels for gluten

content (check as many as apply):

Beverages,Dental

products,Food,Lip

care/cosmetic

products,Other

cosmetics,Lotions,Medicatio

ns,Shampoo and

conditioner,Other hair care

products,Nutritional

supplements,Vitamins,Other

product(s)

Gluten-Related

Disorder History

Dietary

Adherence Please describe the other product(s):

Gluten-Related

Disorder History

Dietary

Adherence

A product must contain a certification

symbol by a gluten-free certification

organization for me to ingest/apply it. Yes,No

Gluten-Related

Disorder History

Dietary

Gluten-Related

Disorder History

Dietary

Adherence

Which products (check as many as

apply):

Beverages,Dental

products,Food,Lip

care/cosmetic

products,Other


ns,Nutritional

supplements,Shampoo and


products,Vitamins,Other

product(s)

Gluten-Related

Disorder History

Dietary

Adherence

A product package must contain the

words gluten-free for me to ingest/apply

it. Yes,No

Gluten-Related

Disorder History

Dietary

Adherence

Which products (check as many as

apply):

Beverages,Dental

products,Food,Lip

care/cosmetic

products,Other


ns,Nutritional

supplements,Shampoo and


products,Vitamins,Other

product(s)

Gluten-Related

Disorder History

Dietary


Gluten-Related

Disorder History

Dietary

Adherence

I avoid products labeled gluten-free that

are labeled "made in a factory that also

processes wheat products". Yes,No

Gluten-Related

Disorder History

Dietary

Adherence I avoid these products because:

Gluten-Related

Disorder History

Dietary

Adherence

I avoid products not labeled gluten-free

that list no gluten-containing ingredients,

but are labeled "made in a factory that

also processes wheat products." Yes,No

Gluten-Related

Disorder History

Dietary

Adherence I avoid these products because:

Gluten-Related

Disorder History

Dietary

Adherence

I am annoyed or frustrated about the

taste of gluten-free food.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence

I am concerned about the nutritional

value of gluten-free food.


en,Always

Gluten-Related

Disorder History

Dietary

Adherence

Do you use supplements to aid in the

digestion of gluten? Yes,No

Gluten-Related

Disorder History

Dietary

Adherence

Please describe which supplements you

take:

Gluten-Related

Disorder History

Dietary

Adherence

Are you familiar with gluten-free dental

products? Yes,No

Gluten-Related

Disorder History

Dietary

Adherence

The importance to my health of

accidental gluten exposure is:

Not at all important,A little

important,Neutral/Don't

know,Somewhat

important,Very important

Gluten-Related

Disorder History

Dietary

Adherence

In the past 30 days, the number of

times I have eaten foods containing

gluten on purpose is: 0 (never),1-2,3-5,6-10,>10

Gluten-Related

Disorder History

Dietary

Adherence

In the past 30 days, the number of

times I have been inadvertently exposed

to gluten is: 0 (never),1-2,3-5,6-10,> 10

Gluten-Related

Disorder History

Dietary

Adherence

In the past 12 months, the number of

work/school days I have missed due to

illness from gluten exposure is:

Gluten-Related

Disorder History

Dietary

Adherence

In the past 12 months, the number of

work/school days I have missed due to

my gluten-related disorder is:

Gluten-Related

Disorder History

Gluten-

Related

Disorder About this section:

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel limited by my gluten-related

disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel worried that I will suffer from my

gluten-related disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel concerned that my gluten-related

disorder will cause other health

problems.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel worried about my increased risk of

cancer from my gluten-related disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel socially stigmatized for having this


Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel like I am limited in eating meals

with coworkers.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel like I am not able to have special

foods like birthday cake and pizza.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel that the gluten-free diet is

sufficient treatment for my gluten-

related disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel that there are not enough choices

for treatment for my gluten-related

disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel depressed because of my gluten-

related disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel frightened by having this gluten-

related disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel like I don't know enough about

this gluten-related disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel overwhelmed about having this


Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I have trouble socializing because of my


Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I find it difficult to travel or take long

trips because of my gluten-related

disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel like I cannot live a normal life

because of my gluten-related disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel afraid to go out because my food

may be contaminated with gluten.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel worried about the increased risk of

one of my family members having this


Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns I feel like I think about food all the time.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel concerned that my long-term

health will be affected by my gluten-

related disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel I have been discriminated against

because of my gluten-related disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel affected by the lack of support of

friends or family members for my gluten-

related disorder.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel annoyed by others lack of

understanding about my gluten-related

disorder and/or dietary needs (e.g.

dismissing it as a lifestyle choice).

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel guilty about the impact of my

gluten-related disorder on friends, family

members or caregivers.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel there are specific activities that are

important to me that I cannot do at all

or as fully as I would like because of my

gluten-related disorder. Yes,No,Don't know

Gluten-Related

Disorder History

Gluten-

Related

Disorder

The specific activities that are important

to me are:

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel it is the gluten-free diet not my

disorder that is most burdensome for

me.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Concerns

I feel it is the gluten-free diet not my

disorder that is most burdensome to

others.

Not at all,A little


bit,Very Much

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Please describe the ways in which

friends, family or caregivers are most

affected:

Gluten-Related

Disorder History

Gluten-

Related Introduction to this section...

Gluten-Related

Disorder History

Gluten-

Related

Medical

History As an infant I was fed:

Breast milk,Formula,Cow's

milk,Other,Don't know

Gluten-Related

Disorder History

Gluten-

Related Please describe other:

Gluten-Related

Disorder History

Gluten-

Related

Medical

History

The age that gluten was introduced into

my diet was:

Don't know,Under 1 year,1

year,2 years,3 years,4

years,5 years,6 years,7


years,Over 10 years,Never

Gluten-Related

Disorder History

Gluten-

Related

The age (in months) that gluten was

introduced into my diet:

Gluten-Related

Disorder History

Gluten-

Related

Medical

History I was born by this mode of birth:

Emergency,C-

section,Scheduled C-

section,Vaginal,Don't know

Gluten-Related

Disorder History

Gluten-

Related I was prescribed antibiotics as a child. Yes,No,Don't Know

Gluten-Related

Disorder History

Gluten-

Related

Medical

History

How frequently were you prescribed

antibiotics during your childhood?

Less than once per year,1-2

times per year,More than 3

times per year,Don't know

Gluten-Related

Disorder History

Gluten-

Related

Medical

History

I was this old when I first received

antibiotics:

Don't know,Less than 4








years old,18 years old

Gluten-Related

Disorder History

Gluten-

Related

I was this old (in months) when I first

received antibiotics:

Gluten-Related

Disorder History

Family

History About this section:

Gluten-Related

Disorder History

Family

History

I have a family member with Celiac

Disease. Yes,No,Don't know

Gluten-Related

Disorder History

Family

History

Please select all family members with

Celiac Disease:

Parent,Sibling,Child,Aunt,Un

cle,Grandmother,Grandfathe

r,Niece,Nephew,Cousin,Half-

Sibling

Gluten-Related

Disorder History

Family

History

I have a family member with Non-Celiac

Gluten Sensitivity. Yes,No,Don't know

Gluten-Related

Disorder History

Family

History

Please select all family members with

Non-Celiac Gluten Sensitivity:

Parent,Sibling,Child,Aunt,Un

cle,Grandmother,Grandfathe

r,Niece,Nephew,Cousin,Half-

Sibling

Gluten-Related

Disorder History

Family

History

Other conditions and autoimmune

disorders that a first degree relative

(parent, sibling or child) experiences are


Addison's Disease

,Autoimmune Hepatitis

,Autoimmune Pancreatitis

,Crohn's Disease;

Inflammatory Bowel Disease

,Dental enamel defects or

frequent mouth sores

(aphthous ulcers),Down

Syndrome ,Idiopathic

Dilated Cardiomyopathy

,IgA Nephropathy ,Irrtitable

Bowel Syndrome (IBS)

,Juvenile Idiopathic Arthritis

,Multiple Sclerosis

,None,Don't know

Gluten-Related

Disorder History

Family

History

Additional conditions and autoimmune

disorders that a first degree relative

(parent, sibling or child) experiences are


Primary Biliary Cirrhosis

,Primary Sclerosing

Cholangitis ,Psoriasis

,Rheumatoid Arthritis

,Scleroderma ,Sjogren's

Disease ,Thyroid Disease

,Turner Syndrome ,Type I

Diabetes ,Ulcerative Colitis;


,Williams Syndrome

,None,Don't know

Gluten-Related

Disorder History

Family

History


disorders that a second degree relative

(aunt, uncle, grandparent, niece,

nephew, cousin, half-sibling) experiences

are (check as many as apply):

Addison's Disease

,Autoimmune Hepatitis

,Autoimmune Pancreatitis

,Crohn's Disease;


,Down Syndrome ,Idiopathic

Dilated Cardiomyopathy

,IgA Nephropathy ,Irrtitable

Bowel Syndrome (IBS)

,Juvenile Idiopathic Arthritis

,Multiple Sclerosis

,None,Don't know

Gluten-Related

Disorder History

Family

History

Additional conditions and autoimmune

disorders that a second degree relative

(aunt, uncle, grandparent, niece,

nephew, cousin, half-sibling) experiences

are (check as many as apply):

Primary Biliary Cirrhosis

,Primary Sclerosing

Cholangitis ,Psoriasis

,Rheumatoid Arthritis

,Scleroderma ,Sjogren's

Disease ,Thyroid Disease

,Turner Syndrome ,Type I

Diabetes ,Ulcerative Colitis;


,Williams Syndrome ,None

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms About this section...

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

I experience the following general

conditions:

Diagnosed prior to gluten-

related diagnosis,Currently

experiencing ,Don't

know,Never experienced

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

I experience the following general

conditions (continued):



experiencing,Don't


Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

Prior to diagnosis of my gluten-related

disorder I experienced the following

behavioral or central nervous system

conditions:

Never,Daily,Weekly,Monthly,

Once in a while,Don't know

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

I currently experience the following

behavioral or central nervous system

conditions:



Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms



gastrointestinal symptoms:



Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms



gastrointestinal symptoms (continued):



Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions



Abdominal pain or

discomfort in upper

abdomen or pit of

stomach,Acid reflux

(Heartburn),Black, tarry

stool,Bloating of

stomach,Blood in

stool,Constipation (fewer

than 3 bowel movements in

7 days),Diarrhea,Difficulty

swallowing,Feeling of not

completely emptying bowels

while on toilet,Food

cravings,Gas,Hunger

pains,Poor

appetite,Nausea,Pain when

swallowing,Pale, foul-

smelling stool,Rumbling of

stomach,Vomiting

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms





Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms


gastrointestinal symptoms (continued):



Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

I experience the following additional

gastrointestinal conditions:



experiencing,Don't


Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

I experience the following muscular

skeletal conditions:



experiencing,Don't


Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

I experience the following reproductive

conditions:



experiencing,Don't


Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

I experience the following dental and

skin conditions:



experiencing,Don't


Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

The type of cancer that I have

experienced is:



experiencing,Don't


Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms Please describe the other cancer(s):

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions


disorders that I experienced are:


related diagnosis,Diagnosed

after gluten-related

diagnosis,Don't know,Never

experienced

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions


disorders that I experienced are

(continued):


related diagnosis,Diagnosed

after gluten-related

diagnosis,Don't know,Never

experienced

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions Over time my symptoms have:

Improved on the gluten-free

diet,Remained the same

since a gluten-free diet was

adopted,Gotten worse since

adopting the gluten-free

diet,Not adopted the gluten-

free diet to treat

symptoms,Do not have

symptoms,Don't know

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions My symptoms:

Come and go,Are

ongoing,Do not have

symptoms,Don't know

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

I develop symptoms within this exposure

to gluten:

Under 2 hours,2-24

hours,More than 24

hours,Do not develop

symptoms when exposed to

gluten,Don't know

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

Upon gluten exposure, I feel negative

symptoms for:

1-2 days,3-4 days,5-6

days,7-10 days,10-14

days,More than 14 days,Do

not develop symptoms when

exposed to gluten,Don't

know

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

The most troublesome symptoms I

experience when exposed to gluten are


Abdominal

pain,Bloating,Bone or joint

pain,Canker sores inside the

mouth,Constipation,Diarrhea

,Depression or

anxiety,Dermatitis

Herpetiformis or skin

rash,Difficulty thinking

clearly (brain

fog),Fatigue,Flatulence

(gas),Headache,Nausea,Migr

aine,Vomiting,Other

symptom(s),Symptoms are

not toublesome,Do not

experience symptoms

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

Please describe the other most

troublesome symptoms:

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

The gluten-free diet lessens these

symptoms and conditions for me (check

as many as apply):

Abdominal pain,Acid

reflux,Arthritis,Bloating,Bon

e or joint pain,Bone loss or

osteoporosis,Canker sores

inside the mouth,Chronic

diarrhea,Constipation,Depre

ssion or anxiety,Dermatitis

Herpetiformis or skin

rash,Difficulty thinking

clearly (brain

fog),Fatigue,Flatulence

(gas),Headache,Irritability,L

ack of muscle coordination

(ataxia),Nausea,Pale, foul-

smelling stool,Seizures or

migraines,Unexplained iron-

deficiency

anemia,Vomiting,Weight

loss,Other,None,Don't know

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

The other symptom(s) lessened or

stopped by the gluten-free diet are:

Gluten-Related

Disorder History

Gluten-

Related

Disorder

Symptoms

and

Conditions

The gluten-free diet treats my most

significant symptoms:

Not at all,A little


bit,Very much,Do not have

symptoms,Don't know

Gluten-Related

Disorder History

We need just

a bit more

information...

This next section will ask questions

specific to the gastrointestinal symptoms

you reported earlier.

Gluten-Related

Disorder History

Gastrointesti

nal - Nausea

and Vomiting In the past 7 days, I had nausea:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal - Nausea

and Vomiting

In past 7 days, I knew that I would have

nausea before it happened:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal - Nausea

and Vomiting

In the past 7 days, I had a poor

appetite:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal - Nausea

and Vomiting

In the past 7 days, I threw up or

vomited:

Never,One day,2-6

days,Once a day,More than

once a day

Gluten-Related

Disorder History

Gastrointesti

nal -

Constipation

In the past 7 days, I passed very hard

or lumpy stools:

Never,One day,2-6


once a day

Gluten-Related

Disorder History

Gastrointesti

nal -

Constipation

In the past 7 days, the hard or lumpy

stools bothered me:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal -

Constipation

In the past 7 days, I strained while

trying to have bowel movements:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal -

Constipation

In the past 7 days, I usually strain while

trying to have a bowel movement:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal -

Constipation

In the past 7 days, straining during

bowel movements bothered me:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal -

Constipation

In the past 7 days, I felt pain in my

rectum or anus while trying to have

bowel movements:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Constipation

In the past 7 days, at its worst, I would

rate the pain in my rectum or anus

during bowel movements as:

Not bad at all,A little

bad,Somewhat bad,Quite

bad,Very bad

Gluten-Related

Disorder History

Gastrointesti

nal -

Constipation

In the past 7 days, a bowel movement

made me feel unfinished; that is, that I

had not passed all my stool:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Constipation

In the past 7 days, I used my finger or

toilet paper to get out a stool:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph Reflux

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

ageal Reflux In the past 7 days, I had regurgitation:

Never,One day,2-6


once a day

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

ageal Reflux

In the past 7 days, the most food or

liquid I had come back up into my mouth

at one time was enough to fill this much

of my mouth:

None,A little bit of the

mouth,Some of the

mouth,Most of the

mouth,The entire mouth

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

ageal Reflux

In the past 7 days, after eating a meal

food or liquid came back into my throat

or mouth without vomiting:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

In the past 7 days, I reswallowed food

that came back into my throat:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

ageal Reflux

In the past 7 days, I felt like I was going

to burp, but food or liquid came up

instead:

Never,One day,2-6


once a day

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

In the past 7 days, I felt like there was

too much saliva in my mouth:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

ageal Reflux

In the past 7 days, I felt burning behind

my breast bone:

Never,One day,2-6


once a day

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

In the past 7 days, I felt burning in my

throat:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

ageal Reflux In the past 7 days, I burped:

Never,One day,2-6


once a day

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

ageal Reflux

In the past 7 days, my burping bothered

me:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph In the past 7 days, I had the hiccups:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

In the past 7 days, I felt like there was a

lump in my throat:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Gastroesoph

ageal Reflux

In the past 7 days, having a lump in my

throat bothered me:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal - Bowel

Incontinence

In the past 7 days, I had bowel

incontinence—:

No days,1 day,2-3 days,4-5

days,6-7 days

Gluten-Related

Disorder History

Gastrointesti

nal - Bowel

Incontinence

In the past 7 days, I soiled or dirtied my

underwear before getting to a bathroom:


days,6-7 days

Gluten-Related

Disorder History

Gastrointesti

nal - Bowel

Incontinence

In the past 7 days, I leaked stool or

soiled my underwear:


days,6-7 days

Gluten-Related

Disorder History

Gastrointesti

nal - Bowel

Incontinence

In the past 7 days, I thought I was

going to pass gas, but stool or liquid

came out instead:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Disrupted Swallowing Difficulties:

Gluten-Related

Disorder History

Gastrointesti

nal -

Disrupted

In the past 7 days, food got stuck in my

chest when I was eating:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Disrupted

In the past 7 days, food got stuck in my

throat when I was eating:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Disrupted

In the past 7 days, I felt pain in my

chest when swallowing food:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Disrupted

Swallowing

In the past 7 days, I had difficulty

swallowing solid foods like meat, chicken

or raw vegetables, even after lots of

chewing:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Disrupted

Swallowing


swallowing soft foods like ice cream,

apple sauce, or mashed potatoes?


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Disrupted


swallowing liquids:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Disrupted


swallowing pills:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal -

Diarrhea

In the past 7 days, the number of days I

had loose or watery stools:

No days,1 day,2 days,3-5

days,6-7 days

Gluten-Related

Disorder History

Gastrointesti

nal -

Diarrhea

In the past 7 days, having loose or

watery stools interfered with my day-to-

day activities:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal -

Diarrhea

In the past 7 days, having loose or

watery stools bothered me:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal -

Diarrhea

In the past 7 days, I felt like I needed to

empty my bowels right away or else I

would have an accident:

Never,One time during the

past 7 days,2-6 times

during the past 7 days,Often

once a day,More than once

a day

Gluten-Related

Disorder History

Gastrointesti

nal -

Diarrhea

In the past 7 days, feeling like I needed

to empty my bowels right away

interfered with my day-to-day activities:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal -

Diarrhea

In the past 7 days, feeling like I needed

to empty my bowels right away bothered

me:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

In the past 7 days, I had swelling in my

belly. Yes,No

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating

In the past 7 days, the swelling in my

belly got bad.

Not bad at all,A little


bad,Very bad

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating


belly interfered with my day-to-day

activities.

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating


belly bothered me.

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating In the past 7 days, I felt bloated:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating

In the past 7 days, in general, my

bloating was severe:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating

In the past 7 days, at its worst, my

bloating was severe:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating

In the past 7 days, in general, my

bloating felt severe:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating

In the past 7 days, I knew that I would

feel bloated before it happened:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating

In the past 7 days, feeling bloated

interfered with my day-to-day activities:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating

In the past 7 days, feeling bloated

bothered me:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating In the past 7 days, I passed gas:

Never,Only once or twice a

day,About every 3-4

hours,About every 2

hours,About ever hour

Gluten-Related

Disorder History

Gastrointesti

nal - Gas or

Bloating

In the past 7 days, I had a gurgling or

rumbling in my belly when I was not

hungry:


en,Always

Gluten-Related

Disorder History

Gastrointesti

nal - Belly

Pain In the past 7 days, I had belly pain:

Never,One Day,2-6

Days,Once a Day,More than

Once a Day

Gluten-Related

Disorder History

Gastrointesti

nal - Belly

Pain

In the past 7 days, at its worst, my belly

pain was:

Not bad,A little


bad,Very bad

Gluten-Related

Disorder History

Gastrointesti

nal - Belly

Pain

In the past 7 days, my belly pain

interfered with my day-to-day activities

Never ,One Day ,2-6

Days,Once a Day,More than

Once a Day

Gluten-Related

Disorder History

Gastrointesti

nal - Belly

Pain

In the past 7 days, my belly pain

bothered me:

Not at all,A little


bit,Very much

Gluten-Related

Disorder History

Gastrointesti

nal - Belly

Pain

In the past 7 days, I had discomfort in

my belly:


en,Always

Reproductive Health

About this

section:

Infertility is a topic of concern for people

with celiac disease. This section asks

questions about your reproductive

history.

Reproductive Health

Female

Reproduction Introduction

Reproductive Health

Female

Reproduction I have started menstruation.. Yes,No,Don't know

Reproductive Health

Female

Reproduction I began menstruating at age..

Do not know,Younger than 7





years,Older than 18 years

Reproductive Health

Female

Reproduction

I would describe my menstrual cycles

as..

No concerns,Regular

menstrual cycles,Irregular

menstrual cycles,Taking

medication to control

menstrual cycles,Heavy

bleeding during menstrual

periods,Light, spotty

bleeding during menstrual

periods,Vaginal bleeding

that is not part of menstrual

cycles,Menstrual period

typically lasts longer than 1

week

Reproductive Health

Female

Reproduction I have sought to conceive a pregnancy... Yes,No,Don't know

Reproductive Health

Female

Reproduction I have had fertility issues... Yes,No,Don't know

Reproductive Health

Female

Reproduction I have used in vitro-fertilization (IVF)... Yes,No,Don't know

Reproductive Health

Female

Reproduction

Including live births, stillbirths,

miscarriages, abortions, and tubal and

other ectopic pregnancies, I have been

pregnant ___ times

0,1,2,3,4,5,6,7,8,9,10,More

than 10 times

Reproductive Health

Female

Reproduction My 1st pregnancy was a...

Live

birth,Stillbirth,Miscarriage,A

bortion,Ectopic/Tubal,Curren

tly pregnant,Other

Reproductive Health

Female

Reproduction My 1st pregnancy was a...

Reproductive Health

Female

Reproduction My pregnancy was over in the...

Months 1-3 (First

Trimester),Months 4-6

(Second Trimester),Months

7-9 (Third Trimester)

Reproductive Health

Female

Reproduction My 1st pregnancy ended on this date...

Reproductive Health

Female

Reproduction

During the 1st pregnancy, I had frequent

nausea or vomiting...

Yes, Nausea,Yes,

Vomiting,Neither

Reproductive Health

Female

Reproduction

In these months of the pregnancy I had

frequent nausea or vomiting...

Months 1-3 (First




Reproductive Health

Female

Reproduction During the 1st pregnancy, I developed... Yes,No

Reproductive Health

Female

Reproduction

The other pregnancy-related

complications were...

Reproductive Health

Female

Reproduction The mode of birth was...

Vaginal delivery,Caesarean

delivery (C-section),Other

Reproductive Health

Female

Reproduction The baby was a... Girl,Boy

Reproductive Health

Female

Reproduction

During the 3 months before I

got pregnant, I smoked ___ cigarettes

on an average day...

41 cigarettes or more,21 to

40 cigarettes,11 to 20

cigarettes,6 to 10

cigarettes,1 to 5

cigarettes,Less than 1

cigarette,None (0

cigarettes)

Reproductive Health

Female

Reproduction

During the 3 months before I got

pregnant, I drank ___ alcoholic drinks in

an average week...

14 drinks or more a week,7

to 13 drinks a week,4 to 6

drinks a week,1 to 3 drinks

a week,Less than 1 drink a

week,None (0 drinks)

Reproductive Health

Female

Reproduction


pregnant, I drank 4 alcoholic drinks or

more in one sitting this many times...

6 or more times,4 to 5

times,2 to 3 times,1

time,Never had 4 drinks or

more in 1 sitting

Reproductive Health

Female

Reproduction

During the 1st pregnancy, I received

help with an alcohol or drug problem... Yes,No

Reproductive Health

Female

Reproduction My 2nd pregnancy was a...

Live



tly pregnant,Other

Reproductive Health

Female

Reproduction My 2nd pregnancy was a...

Reproductive Health

Female

Reproduction My 2nd pregnancy was over in the...

Months 1-3 (First




Reproductive Health

Female

Reproduction My 2nd pregnancy ended on this date...

Reproductive Health

Female

Reproduction

During the 2nd pregnancy, I had


Yes, Nausea,Yes,

Vomiting,Neither

Reproductive Health

Female

Reproduction

In these months of the 2nd pregnancy I

had frequent nausea or vomiting...

Months 1-3 (First




Reproductive Health

Female

Reproduction

During the 2nd pregnancy, I

developed... Yes,No

Reproductive Health

Female

Reproduction



Reproductive Health

Female

Reproductive Health

Female

Reproduction






cigarettes,6 to 10

cigarettes,1 to 5


cigarette,None (0

cigarettes)

Reproductive Health

Female

Reproduction



an average week...






Reproductive Health

Female

Reproduction







more in 1 sitting

Reproductive Health

Female

Reproduction

During the 2nd pregnancy, I received


Reproductive Health

Female

Reproduction My 3rd pregnancy was a...

Live



tly pregnant,Other

Reproductive Health

Female

Reproduction My 3rd pregnancy was a...

Reproductive Health

Female

Reproduction My 3rd pregnancy was over in the...

Months 1-3 (First




Reproductive Health

Female

Reproduction My 3rd pregnancy ended on this date...

Reproductive Health

Female

Reproduction

During the 3rd pregnancy, I had


Yes, Nausea,Yes,

Vomiting,Neither

Reproductive Health

Female

Reproduction

In these months of the 3rd pregnancy I


Months 1-3 (First




Reproductive Health

Female

Reproduction During the 3rd pregnancy, I developed... Yes,No

Reproductive Health

Female

Reproduction



Reproductive Health

Female


Reproductive Health

Female

Reproduction






cigarettes,6 to 10

cigarettes,1 to 5


cigarette,None (0

cigarettes)

Reproductive Health

Female

Reproduction



an average week...






Reproductive Health

Female

Reproduction







more in 1 sitting

Reproductive Health

Female

Reproduction

During the 3rd pregnancy, I received


Reproductive Health

Female

Reproduction My 4th pregnancy was a...

Live



tly pregnant,Other

Reproductive Health

Female


Reproductive Health

Female

Reproduction My 4th pregnancy was over in the...

Months 1-3 (First




Reproductive Health

Female

Reproduction My 4th pregnancy ended on this date...

Reproductive Health

Female

Reproduction

During the 4th pregnancy, I had


Yes, Nausea,Yes,

Vomiting,Neither

Reproductive Health

Female

Reproduction

In these months of the 4th pregnancy I


Months 1-3 (First




Reproductive Health

Female

Reproduction During the 4th pregnancy, I developed... Yes,No

Reproductive Health

Female

Reproduction



Reproductive Health

Female


Reproductive Health

Female

Reproduction






cigarettes,6 to 10

cigarettes,1 to 5


cigarette,None (0

cigarettes)

Reproductive Health

Female

Reproduction



an average week...






Reproductive Health

Female

Reproduction







more in 1 sitting

Reproductive Health

Female

Reproduction

During the 4th pregnancy, I received


Reproductive Health

Female


Live



tly pregnant,Other

Reproductive Health

Female


Reproductive Health

Female


Months 1-3 (First




Reproductive Health

Female


Reproductive Health

Female

Reproduction



Yes, Nausea,Yes,

Vomiting,Neither

Reproductive Health

Female

Reproduction



Months 1-3 (First




Reproductive Health

Female


Reproductive Health

Female

Reproduction



Reproductive Health

Female


Reproductive Health

Female

Reproduction






cigarettes,6 to 10

cigarettes,1 to 5


cigarette,None (0

cigarettes)

Reproductive Health

Female

Reproduction



an average week...






Reproductive Health

Female

Reproduction







more in 1 sitting

Reproductive Health

Female

Reproduction



Reproductive Health

Female


Live



tly pregnant,Other

Reproductive Health

Female


Reproductive Health

Female


Months 1-3 (First




Reproductive Health

Female


Reproductive Health

Female

Reproduction



Yes, Nausea,Yes,

Vomiting,Neither

Reproductive Health

Female

Reproduction



Months 1-3 (First




Reproductive Health

Female

Reproduction During the 6th pregnancy, I developed Yes,No

Reproductive Health

Female

Reproduction

The other pregnancy related


Reproductive Health

Female

Reproduction The baby was a.. Girl,Boy

Reproductive Health

Female

Reproduction






cigarettes,6 to 10

cigarettes,1 to 5


cigarette,None (0

cigarettes)

Reproductive Health

Female

Reproduction



an average week...






Reproductive Health

Female

Reproduction







more in 1 sitting

Reproductive Health

Female

Reproduction



Reproductive Health

Female


Live



tly pregnant,Other

Reproductive Health

Female


Reproductive Health

Female


Months 1-3 (First




Reproductive Health

Female


Reproductive Health

Female

Reproduction



Yes, Nausea,Yes,

Vomiting,Neither

Reproductive Health

Female

Reproduction



Months 1-3 (First




Reproductive Health

Female


Reproductive Health

Female

Reproduction



Reproductive Health

Female


Reproductive Health

Female

Reproduction






cigarettes,6 to 10

cigarettes,1 to 5


cigarette,None (0

cigarettes)

Reproductive Health

Female

Reproduction



an average week...






Reproductive Health

Female

Reproduction







more in 1 sitting

Reproductive Health

Female

Reproduction



Reproductive Health

Female


Live



tly pregnant,Other

Reproductive Health

Female


Reproductive Health

Female


Months 1-3 (First




Reproductive Health

Female

Reproduction The 8th pregnancy ended on this date...

Reproductive Health

Female

Reproduction



Yes, Nausea,Yes,

Vomiting,Neither

Reproductive Health

Female

Reproduction



Months 1-3 (First




Reproductive Health

Female


Reproductive Health

Female

Reproduction



Reproductive Health

Female

Reproduction The baby was a.. Girl,Boy

Reproductive Health

Female

Reproduction






cigarettes,6 to 10

cigarettes,1 to 5


cigarette,None (0

cigarettes)

Reproductive Health

Female

Reproduction



an average week...






Reproductive Health

Female

Reproduction







more in 1 sitting

Reproductive Health

Female

Reproduction



Reproductive Health

Female


Live


bortion,Ectopic/Tubal,Other

Reproductive Health

Female


Reproductive Health

Female


Months 1-3 (First




Reproductive Health

Female


Reproductive Health

Female

Reproduction



Yes, Nausea,Yes,

Vomiting,Neither

Reproductive Health

Female

Reproduction



Months 1-3 (First




Reproductive Health

Female


Reproductive Health

Female

Reproduction



Reproductive Health

Female


Reproductive Health

Female

Reproduction






cigarettes,6 to 10

cigarettes,1 to 5


cigarette,None (0

cigarettes)

Reproductive Health

Female

Reproduction



an average week...






Reproductive Health

Female

Reproduction







more in 1 sitting

Reproductive Health

Female

Reproduction



Reproductive Health

Female


Live


bortion,Ectopic/Tubal,Other

Reproductive Health

Female


Reproductive Health

Female


Months 1-3 (First




Reproductive Health

Female


Reproductive Health

Female

Reproduction



Yes, Nausea,Yes,

Vomiting,Neither

Reproductive Health

Female

Reproduction



Months 1-3 (First




Reproductive Health

Female

Reproduction

During the 10th pregnancy, I

developed... Yes,No

Reproductive Health

Female

Reproduction



Reproductive Health

Female


Reproductive Health

Female

Reproduction






cigarettes,6 to 10

cigarettes,1 to 5


cigarette,None (0

cigarettes)

Reproductive Health

Female

Reproduction



an average week...






Reproductive Health

Female

Reproduction







more in 1 sitting

Reproductive Health

Female

Reproduction



Reproductive Health

Male

Reproduction

I have fathered a pregnancy (regardless

of outcome)... Yes,No,Don't know

Reproductive Health

Male

Reproduction

I have fathered ___ pregnancies

(regardless of outcome)...

1,2,3,4,5,6,7,8,9,10,More

than 10

Reproductive Health

Male

Reproduction

I was ____ years old when I fathered

my 1st pregnancy...

Under the age of 12,12










years old,Over the age of 30

Reproductive Health

Male

Reproduction This was a planned pregnancy... Yes,No

Reproductive Health

Male

Reproduction I have had fertility issues... Yes,No,Don't know

Reproductive Health

Male

Reproduction

I have used in vitro-fertilization (IVF)

and/or testicular sperm extraction

(TESE)... Yes,No,Don't Know

Reproductive Health

Male

Reproduction


my 2nd pregnancy...












Reproductive Health

Male

Reproduction The 2nd pregnancy was planned... Yes,No,Don't Know

Reproductive Health

Male

Reproduction

I had fertility issues during the 2nd

pregnancy... Yes,No,Don't Know

Reproductive Health

Male

Reproduction

I used in vitro-fertilization (IVF) and/or

testicular sperm extraction (TESE)

during the 2nd pregnancy... Yes,No,Don't Know

Reproductive Health

Male

Reproduction


my 3rd pregnancy...












Reproductive Health

Male

Reproduction The 3rd pregnancy was planned...... Yes,No,Don't Know

Reproductive Health

Male

Reproduction

I had fertility issues during the 3rd


Reproductive Health

Male

Reproduction



during the 3rd pregnancy... Yes,No,Don't Know

Reproductive Health

Male

Reproduction


my 4th pregnancy...












Reproductive Health

Male

Reproduction The 4th pregnancy was planned... Yes,No,Don't Know

Reproductive Health

Male

Reproduction

I had fertility issues during the 4th


Reproductive Health

Male

Reproduction



during the 4th pregnancy... Yes,No,Don't Know

Reproductive Health

Male

Reproduction


my 5th pregnancy...












Reproductive Health

Male

Reproduction This 5th pregnancy was a planned... Yes,No,Don't Know

Reproductive Health

Male

Reproduction



Reproductive Health

Male

Reproduction




Reproductive Health

Male

Reproduction


my 6th pregnancy...












Reproductive Health

Male


Reproductive Health

Male

Reproduction



Reproductive Health

Male

Reproduction



during the 6th pregnancy... Yes,No,Don't know

Reproductive Health

Male

Reproduction


my 7th pregnancy...












Reproductive Health

Male


Reproductive Health

Male

Reproduction



Reproductive Health

Male

Reproduction




Reproductive Health

Male

Reproduction


my 8th pregnancy...












Reproductive Health

Male


Reproductive Health

Male

Reproduction



Reproductive Health

Male

Reproduction




Reproductive Health

Male

Reproduction


my 9th pregnancy...












Reproductive Health

Male


Reproductive Health

Male

Reproduction



Reproductive Health

Male

Reproduction




Reproductive Health

Male

Reproduction


my 10th pregnancy...












Reproductive Health

Male


Reproductive Health

Male

Reproduction



Reproductive Health

Male

Reproduction



during the 10th pregnancy... Yes,No,Don't know

Reproductive Health

Sexual

History About this section...

Reproductive Health

Sexual

History

I am in a relationship that could involve

sexual activity. Yes,No

Reproductive Health

Sexual

History

Fatigue or lack of energy has affected

my satisfaction with my sex life.

Not in the past 30 days,Not

at all,A little


bit,Very Much

Reproductive Health

Sexual

History

Pain has affected my satisfaction with

my sex life.


at all,A little


bit,Very Much

Reproductive Health

Sexual

History

Gastrointestinal symptoms have affected

my satisfaction with my sex life.


at all,A little


bit,Very Much

Reproductive Health

Sexual

History

Other symptoms have affected my

satisfaction with my sex life.


at all,A little


bit,Very Much

Conclusion

Just a few

more

questions to

Conclusion

Just a few

more

questions to

wrap up... celiac_0002

{"setting":"Take only

once","reminderDetails":{"r

eminder_message":""}}

Conclusion

Survey

Feedback

Reflecting on my experience of setting

up an account and responding to the

questionnaire...

Very easy,Fairly easy,Some

parts easy, some parts

difficult,Somewhat

difficult,Very difficult

Conclusion

Survey

Feedback

I felt the process of creating privacy

directives pertaining to who could access

and use my information and for what

purposes was...

Professional,Not

professional,Friendly and

welcoming,Cold and off

putting,Easy to understand

and follow,Confusing,Helped

by the use of guides,More

difficult due to the use of

guides,Conveys a sense of

security,Suspicious,Helpful

in building trust,About the

same as other health

websites

Conclusion

Survey

Feedback

Now that I have registered for the

Private Access service and expressed my

wishes for how my personal health and

contact information should be handled, I

feel...

Complete trust wishes will

be followed exactly as

directed,A general sense of

trust that wishes will be

followed essentially as

directed,Only some trust

that wishes will be followed

as directed,Uncertain

whether wishes will be

followed,A sense of concern

that wishes will not be

followed,Certain that wishes

will not be followed

Conclusion

Survey

Feedback

I felt that being permitted to declare

who could access and use my

information, and for what purposes is...

Conclusion

Survey

Feedback

I found the ability to see how others

responded to the same questions I

answered to be...

Helpful in keeping interest

high,Tiresome or distracting

Conclusion

Survey

Feedback

From start to finish my impression of the

length of time it took...

It took about the right

amount of time,It took less

time than I thought it

would,It took too long, but

it was worth it,It took too

long

Conclusion

Survey

Feedback

I used a screen reader technology to

complete the survey... Yes,No

Conclusion

Survey

Feedback

The screen reader did or did not work

for me...

Yes, the screen reader

worked well and I could

complete the survey,Screen

reader worked for most of

the questions,I was unable

to complete the survey with

my screen reader,Not

applicable

Conclusion Thank you!

Thank you for completing this survey.

We appreciate your contributions.



Please check your email for regular

updates on how your participation is

helping in the fight against celiac disease

and gluten sensitivity.

To contact us about this survey, or any

other matters, please email us at

[email protected]

topic instrument question responses...ethnicity the name of my tribe is... background about this...

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